Score |
Term |
Description |
+4 |
Combative |
Overtly combative or violent, immediate danger to staff |
+3 |
Very agitated |
Pulls on or removes tubes or catheters, aggressive behavior toward staff |
+2 |
Agitated |
Frequent nonpurposeful movement or patient-ventilator dyssynchrony |
+1 |
Restless |
Anxious or apprehensive but movements not aggressive or vigorous |
0 |
Alert and calm |
|
-1 |
Drowsy |
Not fully alert, sustained (>10 seconds) awakening, eye contact to voice |
-2 |
Light sedation |
Briefly (<10 seconds) awakens with eye contact to voice |
-3 |
Moderate sedation |
Any movement (but no eye contact) to voice |
-4 |
Deep sedation |
No response to voice, any movement to physical stimulation |
-5 |
Unarousable |
No response to voice or physical stimulation |
Procedure |
1. |
Observe patient. Is patient alert and calm (score 0)? |
2. |
Does patient have behavior that is consistent with restlessness or agitation? |
Assign score +1 to +4 using the criteria listed above. |
3. |
If patient is not alert, in a loud speaking voice state patient's name and direct patient to open
eyes and look at speaker. Repeat once if necessary. Can prompt patient to continue looking at speaker. |
Patient has eye opening and eye contact, which is sustained for more than 10 seconds (score -1). |
Patient has eye opening and eye contact, but this is not sustained for 10 seconds (score -2). |
Patient has any movement in response to voice, excluding eye contact (score -3). |
4. |
If patient does not respond to voice, physically stimulate patient by shaking shoulder and then rubbing sternum if there is no response. |
Patient has any movement to physical stimulation (score -4). |
Patient has no response to voice or physical stimulation (score -5). |